Pregnancy hormone combination for treatment of autoimmune diseases

ABSTRACT

The present invention relates to pregnancy hormone combinations and methods of treatment for autoimmune diseases having at least two hormonal components, a pregnancy hormone (such as estriol), and a gestagen (such as levonorgestrel or norethindrone) thereby providing for the continuous, uninterrupted administration of pregnancy hormones for the treatment for autoimmune disorders, such as multiple sclerosis.

This application is a continuation application of U.S. patentapplication Ser. No. 12/451,892, filed on Dec. 4, 2009, which is acontinuation-in-part application of U.S. patent application Ser. No.11/151,040, filed on Jun. 13, 2005 and issued as U.S. Pat. No.8,372,826, which is a continuation of U.S. patent application Ser. No.10/131,834, filed on Apr. 24, 2002 and issued as U.S. Pat. No.6,936,599, which in turn claims priority to U.S. Provisional PatentApplication No. 60/286,842, filed on Apr. 25, 2001.

This application is a continuation application of U.S. patentapplication Ser. No. 12/451,892, filed on Dec. 4, 2009, which is anational phase application of International Patent Application No.PCT/US2008/007065, filed on Jun. 4, 2008, which claims priority to U.S.Provisional Patent Application No. 60/933,030, filed on Jun. 4, 2007,both of which are incorporated by reference herein.

BACKGROUND OF THE INVENTION

1. Field of the Invention

This invention relates generally to therapies for treating autoimmunediseases and, more particularly, to administering primary agents beingestrogens or estrogen receptor active agents for the treatment of cellmediated diseases. In combination, secondary agents which effect theimmune system are also administered. Finally, treatment kits areprovided containing at least one primary agent and at least onesecondary agent for treating a patient presenting with symptomology ofan autoimmune disease.

More specifically, the present invention may comprise a combination of apregnancy hormone (such as estriol), combined with a gestagen (such aslevonorgestrel or norethindrone) for treating autoimmune diseases. Thecombination may be useful at least for the continuous treatment andprevention of relapses in patients having an autoimmune disease, such asmultiple sclerosis, obviating the need for pregnancy hormone therapyholidays for menstruation that may be associated with higher rates ofrelapse of disease during such holiday.

2. General Background and State of the Art

There is a distinct female preponderance of autoimmune diseases duringthe reproductive ages including multiple sclerosis (MS), rheumatoidarthritis (RA), uveitis, myesthenia gravis (MG), Sjogren's syndrome,Hashimoto's thyroiditis, psoriasis, and lupus.

For example, MS is a chronic, and often debilitating disease affectingthe central nervous system (brain and spinal cord). MS affects more than1 million people worldwide and is the most common neurological diseaseamong young adults, particularly woman. The exact cause of MS is stillunknown. MS attacks the nervous system resulting in myelin sheathssurrounding neuronal axons to be destroyed. This demyelinization cancause weakness, impaired vision, loss of balance, and poor musclecoordination. MS can have different patterns, sometimes leaving patientsrelatively well after episodes of acute worsening, sometimes leading toprogressive disability that persists after episodes of worsening. In theworst cases the disease can lead to paralysis or blindness.

Steroid hormones or sex-linked gene inheritance may be responsible forthe enhanced susceptibility of women to these autoimmune diseases. Arole for steroid hormones in susceptibility to autoimmune disease issupported by observations of alternations in disease symptomatology,with alterations in sex hormone levels such as during pregnancy. Forexample, women with MS, RA and psoriasis have been reported toexperience remission of symptoms during late gestation. Particularly, MSpatients have been reported to show a decrease in relapse rate inpregnancy.

Normally, cell-mediated immunity is mediated by T helper cell (Th1)secretion of interferon gamma (IFN-γ) and tumor necrosis factor beta(TNF-β). In contrast, humoral immunity is mediated by another group of Thelper cells (Th2) secreting interleukin (IL)-10, IL-4, IL-5 and IL-6. Asystemic shift toward humoral immunity (or Th2-mediated immunity) hasbeen noted during pregnancy. During pregnancy, cell-mediated immunity isdecreased and humoral-mediated immunity is increased thereby promotingfetal survival. Thus, this systemic shift in the immune system mayexplain why cell-mediated diseases, including MS, RA and psoriasis havebeen reported to improve during pregnancy.

Although a shift toward humoral-mediated immunity has been demonstratedduring human pregnancy, mechanisms which induce this shift remainunclear. One possibility is local production of Th2 (or humoralmediated) cytokines by the placenta. Another possibility is theproduction of Th2 cytokines by immune cells, consequent to changedlevels of steroid hormones during pregnancy. Consistent with the latterpossibility, in vitro studies have demonstrated the ability of thesteroid progesterone to increase IL-4 production and the ability of thesteroid 17β-estradiol to increase IL-10 production during T-lymphocyteresponses. However, it remains unclear what cellular mechanisms areinvolved in regulating in vivo amelioration of autoimmune symptomology.

Examples of potential candidates which effect may effect MS duringpregnancy include: Sex hormones (estrogens, progesterone), cortisol,vitamin D, alpha-fetoprotein, human chorionic gonadotropin and pregnancyspecific glycoproteins.

Further, some studies have suggested that a unique pregnancy factortermed “early pregnancy factor” is responsible for improved progressionof cell-mediated autoimmune diseases during pregnancy. Other studieshave suggested a role for microchimerism. Still others suggest a rolefor local factors such as TGFβ or estriol (E3) which is known to beproduced by the placenta during pregnancy. Of note, estriol is at itshighest serum levels in the third trimester of pregnancy. However,estriol's role in ameliorating symptoms of autoimmune diseases in humansis unclear.

Studies in laboratory animals have established that experimentalautoimmune encephalomyelitis (EAE) and other Th1 (cell-mediated)autoimmune diseases in mice improve during pregnancy.

Specifically, treatment with late pregnancy levels of estriol orsupraphysiological doses of estradiol (5 times pregnancy levels) wereshown to delay the onset of clinical EAE after disease wasexperimentally induced by immunization of mice (Jansson, et al., 1994).However, there was no investigation as to how estrogens delayed the dayof onset of disease, nor as to whether disease severity was effected inthese animals once symptomology occurred.

In another study, it was shown that EAE disease severity could bereduced by treatment with estriol, either before or after disease onset.Treatment of EAE mice with 90 day release pellets of 5 milligrams or 15milligrams of estriol was shown not only to decrease disease severitybut also to enhance autoantigen specific humoral-immunity, increaseproduction of the Th2 cytokine IL-10 and reduced inflammation anddemyelination in EAE mice. Importantly, these changes in the diseasewere induced by a dose (5 mg) which was shown to yield estriol levels inserum that were similar to those which occur during late pregnancy (Kim,et al., Neurology, 50 (4 Supp. 4):A242-245, April 1998, FASEB Journal12(4):A616, March 1998 and Neurology 52(6):1230-1238, April 1999; hereinincorporated by reference). Thus, these results suggested that steroidhormones, and estriol in particular, may be involved in the ameliorationof autoimmune reactions in the EAE animal model.

Other groups later demonstrated that estrogen potentiated the effects oftreatment with TCR proteins to reduce autoimmune reactions in EAE mice.Offner, et al., FASEB Journal 14(6):A1246, April 2000; Int. Journal ofMol. Medicine 6 (Supp. 1): S8, October 2000 and Journal of Clin. Invest.105(10):1465-1472, May 2000). Further, it was shown in animal studiesthat estrogen suppressed the onset EAE in mice (Ito, et al., Journal ofImmunology, 167(1): 452-52, 2001) and that presumed diestrus levels ofestrogens reduced some manifestations of active EAE in mice. (Bebo, etal., Journal of Immunology 166(3): 2080-9, 2001.)

However, the etiology and disease progression of EAE and MS are notidentical, thus it is unclear that estrogens alone would be effective inameliorating autoimmune responses in human patients. Indeed, not only isit unknown whether pregnancy doses of estrogens might be protective inhumans with autoimmune disease, it is unclear even in mice whether lowdoses of estrogens are protective. For example, it has been reported bysome that ovariectomy of female mice makes EAE disease worse (Matejuk,et al., 2001), while others have found that ovariectomy had no effect ondisease severity (Kim, et al., 2001; Voskuhl and Palaszynski, 2001a;Voskuhl and Palaszynski, 2001b). Thus, it is controversial whether lowlevels of estrogens, as they exist during the menstrual cycle, areprotective even in mice.

Data from human studies to date have shown no clear benefit of hormonesin treating any autoimmune disease. In humans, administration ofavailable hormone therapies (including HRTs and OCPs) containing amixture of sex hormones cause some autoimmune diseases to improve whileothers worsen.

For example, there has been no conclusive evidence that women areprotected from or have a decrease in symptomology or relapse rates dueto sex steroids. One study noted that past use of oral contraceptives inhealthy women had no effect on subsequent risk to develop MS (Hernan, etal., 2000). Further, another study found that the incidence rates for MSin current users were not decreased as compared to never-users(Thorogood and Hannaford, 1998). Thus, low doses of estrogens in oralcontraceptives are not of sufficient type or dose to ameliorate theimmunopathogenesis of MS even temporarily during intercurrent use. Atbest, in one study, patients had the subjective impression thatpre-existing MS symptoms (as opposed to relapse rates) worsen during thepremenstrual period and that the use of oral contraceptives may havedecreased this worsening (Zorgdrager and De Keyser, 1997). Importantly,the lack of reports of an effect of oral contraceptive therapy on MSrelapses is in marked contrast to what has been observed duringpregnancy.

In contrast, it has been shown that women had a lower risk of developingMS during pregnancy compared to non-pregnant states (Runmarker andAndersen, 1995). Due to the numerous changes that occur duringpregnancy, hormonal and nonhormonal (as listed above), the etiology ofthe beneficial effect of pregnancy may or may not be related to sexsteroid fluctuations. It has also been reported for decades thatpregnancy decreases MS relapses (Abramsky, 1994; Birk, et al., 1990;Birk, et al., 1998; Damek and Shuster, 1997; Runmarker and Andersen,1995; Confavreux, et al., 1998). These studies have shown that thelatter part of pregnancy is associated with a significant reduction inrelapses, while there is a rebound increase in relapses post partum. Incontrast, the absence of such an effect on relapses during OCP or HRTindicate that low level sex steroids are not adequate to treat thesesymptoms.

Further, women having rheumatoid arthritis that were treated with HRTdid not show significant improvement in their symptomology. (DaSilva andHall, Baillieres Clinical Rheumatology 1992, 6:196-219; Bijlsma, et al.,Journal of Repro. Imm. 28(3-4):231-4, 1992; Hall, et al., Annals of theRheumatic Diseases, 53(2): 112-6, 1994.)

Thus, the low doses of hormones found naturally during the menstrualcycle or in ORT and HRT have not been shown to be effective atameliorating the symptomology of autoimmune diseases. This is in spiteof the observation that women having MS have a decreased relapse rateduring late pregnancy. Thus, a challenge has been to identify a hormoneand a treatment dose that is therapeutic in treating particularautoimmune diseases, while minimizing undesirable side effects.Obviously, the dose and method of administration of steroids in humansdiffers from steroid treatment in laboratory animals due to toxiceffects of prolonged exposure by patients to steroid hormones. Inparticular, there are clinical concerns of inducing breast orendometrial cancers in women requiring long term exposure to steroidhormones.

Although not available in the United States, the pregnancy hormoneestriol has been recently prescribed in Europe and Asia largely as anHRT for postmenopausal women. On the other hand, hormonal contraceptiveshave been widely prescribed for premenopausal and perimenopausal womensince the 1960's. Since that time, a number of hormonal components havebeen investigated as to their suitability for administration. Afundamental subdivision into combination and sequential contraceptiveproducts is possible.

For example, if the desired cycle time is 28 days (in the case of theknown combination products) administration takes place over 21 days in aconstant or varying absolute and/or relative dosage of a combination ofan estrogen and a gestagen, in which the estrogen product can, forexample, be natural estrogen or synthetic ethinyl estradiol. The takingof the 21 daily units is followed by a seven-day interval where there isa withdrawal bleeding simulating natural menstruation.

In the known sequential products, for a desired cycle time of 28 days,administration takes place for 7 days of a pure estrogen product andthen for 15 days of a combination of an estrogen product and a gestagenproduct, followed by a taking-free period of, for example, 6 days whenwithdrawal bleeding occurs. It is known to bridge the taking-intervalsof combination and sequential products to administer placebos. However,it has been assumed that during the roughly one-week placebo interval nohormones should be administered, in order to ensure a reliablewithdrawal bleeding.

Only in the case of substitution products in the menopause of olderwomen have hormones been administered continuously throughout the cycle,for example, in the sequence 10 days estrogen product, 11 dayscombination of estrogen and gestagen product, 7 days estrogen product ina particularly low dosage.

German Patent No. 43 08 406 discloses a combination contraceptiveproduct for premenopausal women, which comprises one or more stages. Atleast one stage contains the combination of three components, namely abiogenous estrogen, a synthetic estrogen and a gestagen and the furtherstages in each case comprise a placebo or a biogenous or syntheticgestagen, or a biogenous or synthetic estrogen, or a combination of twocomponents, namely a biogenous estrogen, a synthetic estrogen and agestagen or a combination of synthetic estrogen and a gestagen.

U.S. patent application Ser. No. 10/867,954 filed by Hesch publishedDec. 2, 2004 and assigned to Wyeth Pharmaceuticals, Inc. describesestrogens and gestagens as combination products for continuous hormonalcontraception in premenopausal women, but does not describe their usefor autoimmune disease. Furthermore, although estriol is mentioned as anestrogen in this patent application, the preferred embodimentcontemplates the use estradiol, which is not pregnancy hormone, andutility of which has been clinically proven to be ineffective for thetreatment of autoimmune diseases (such as MS).

The description above makes it clear that in the stage concept there istypically a change of state over the period of time. Such a state changecan take place in that the composition of the phases forming the stageis modified with respect to the components used and in that only theconcentrations of the components used in the phases forming the stageundergo changes.

Consequently, there are no hormone combinations identified for safe andeffective use to delay and/or treat autoimmune diseases, and forpotential continuous therapies.

INVENTION SUMMARY

A general object of the present invention is to provide a method ofadministering hormones to mammals to treat autoimmune related diseases,more particularly, Th1-mediated (cell-mediated) autoimmune diseasesincluding: multiple sclerosis (MS), rheumatoid arthritis (RA),psoriasis, autoimmune thyroiditis, uveitis and other autoimmune diseasesin which clinical symptomology has shown improvement during the thirdterm of pregnancy.

In accordance with one aspect of the present invention, these objectivesare accomplished by providing a treatment for autoimmune relateddiseases with a selected dose and course (including a continuous course)of a primary agent being an estrogen or estrogen receptor-effectivecomposition, such as estriol.

In accordance with one aspect of the present invention, these objectivesare accomplished by providing a patient with a therapeutically effectiveamount of estriol, comprising from about 1 to 20 milligrams per day,about 5 to 10 milligrams per day or more specifically, about 8milligrams once daily via oral administration.

In accordance with another aspect of the present invention, theseobjectives are accomplished by providing a therapeutically effectiveamount of a primary agent in combination with a therapeuticallyeffective amount of a secondary active agent, such as a gestagen (suchas levonorgestrel or norethindrone).

The combination of agents in a continuous administration course may beuseful at least to delay the onset of, prevent or delay relapse or treatpatients exhibiting symptoms of an autoimmune disease, such as multiplesclerosis. Further, the combination may obviate the need for pregnancyhormone therapy holidays for menstruation that may be associated withhigher rates of relapse of disease during such holiday.

In one embodiment, the present invention may comprise a productcomprising and/or method of treatment containing a daily dosage amountof estriol and constant or varied dosages of a gestagen that is usefulfor delaying the onset, preventing relapses, and/or treating thesymptoms of of autoimmune disease, such as, multiple sclerosis,psoriasis, myesthania gravis, rheumatoid arthritis, uveitis, Sjogren'ssyndrome, or Hashimoto's thyroiditis and lupus.

In one embodiment of the invention, the method of treatment may providea continuous, combined administration of a first hormonal componentcomprising at least one estrogen and a second hormonal componentcomprising at least one gestagen.

In one embodiment of the invention, the estrogen as the first hormonalcomponent can be selected from the group comprising synthetic estrogens,biogenous estrogens, antiestrogens and hormonal analogs with estrogen orantiestrogen action. In one embodiment, the synthetic estrogen isestriol.

According to one embodiment of the invention, the biogenous estrogen maybe selected from the group comprising estradiol, estriol, estrone,estrane, etc., as well as hormonal compounds rapidly splitting off atleast one biogenous estrogen after taking. According to one embodimentthe estradiol comprises 17-α-estradiol and/or 17-β-estradiol. Accordingto another embodiment, the daily administered biogenous estrogenquantity in the case of estradiol, particularly α and β-estradiol, is0.1 to 2 mg and in the case of conjugate estrogens 0.05 to 0.5 mg.

According to another embodiment, the gestagen as the secondary agent maybe chosen from the group comprising: progesterone, chlormadinoneacetate, norethisterone acetate, norethindrone, cyproterone acetate,desogestrel, levonorgestrel, other natural and/or synthetic gestagens,antigestagens and hormonal analogs with gestagen or antigestagen action,as well as hormonal compounds which rapidly split off at least onegestagen following taking.

In one embodiment, the daily units comprising both hormonal components,are placed in spatially separated and individually removable manner in apackaging unit. In one embodiment the daily units of both hormonalcomponents may be placed in the packaging unit separately, but whenadministered together form the desired combination.

In one embodiment, the combination may be administered orally. In oneembodiment, the combination may be administered transdermally. In oneembodiment, the combination may be administered intravaginally. In oneembodiment, the combination may be in depot injection form. In oneembodiment, the combination may be administered as a hormonal implant.

In another embodiment of the method according to the invention, thecomposition(s) according to the invention is administered to a subject.

The above described and many other features and attendant advantages ofthe present invention will become apparent from a consideration of thefollowing detailed description when considered in conjunction with theaccompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 a is a schematic depicting the trial design described in Example1; FIG. 1 b is a bar graph depicting human serum levels duringpregnancy, estriol treatment (Tx), and pretreatment (Pre Tx levels).

FIG. 2 a is a bar graph describing the Delayed Type Hypersensitivity(DTH) responses to tetanus and to candida; FIG. 2 b is a bar graphdepicting levels of IFN-γ between treatment groups.

FIG. 3 a-f are bar graphs depicting each patient's gadolinium enhancinglesion volumes on serial cerebral MRIs which were assessed at each monthduring the pretreatment, estriol treatment and post treatment periods.

FIG. 4 is a bar graph depicting mean percent change in PASAT scoresduring treatment with estriol as compared to pretreatment.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

This description is not to be taken in a limiting sense, but is mademerely for the purpose of illustrating the general principles of theinvention. The section titles and overall organization of the presentdetailed description are for the purpose of convenience only and are notintended to limit the present invention.

Generally, the invention involves a method of treating mammal exhibitingclinical symptoms of an autoimmune disease comprising administering aprimary agent and a secondary agent at therapeutically effective dosagesin an effective dosage form at a selected interval. The treatment isaimed at reducing the rate of onset, degree of symptomology and/orprogression of autoimmune disease. In the preferred embodiment of theinvention, human patients clinically diagnosed with MS (including bothrelapsing remitting or secondary progressive type patients) are treatedwith the combination of an estrogen and at least one gestagen.

Amelioration of the symptomology or reduced progression of theautoimmune disease refers to any observable beneficial effect of thetreatment. The beneficial effect can be evidenced by a delayed onset orprogression of disease symptomology, a reduction in the severity of someor all of the clinical symptoms, or an improvement in the overallhealth.

For example, patients who have clinical symptoms of an autoimmunedisease often suffer from some or all of the following symptoms:worsening of pre-existing symptoms (such as joint pain in rheumatoidarthritis), the appearance of new symptoms (new joints affected inrheumatoid arthritis) or increased generalized weakness and fatigue. MSpatients in particular suffer from the following symptoms: weakness,numbness, tingling, loss of vision, memory difficulty and extremefatigue. Thus, an amelioration of disease in MS would include areduction in the frequency or severity of onset of weakness, numbness,tingling, loss of vision, memory difficulty and extreme fatigue. Onimaging of the brain (MRI) amelioration or reduced progression ofdisease would be evidenced by a decrease in the number or volume ofgadolinium enhancing lesions, a stabilization or slowing of theaccumulation of T2 lesions and/or a slowing in the rate of atrophyformation. Immunologically, an increase in Th2 cytokines (such as IL-10)a decrease in Th1 cytokines (such as interferon gamma) would beassociated with disease amelioration.

Patients may also express criteria indicating they are at risk fordeveloping autoimmune diseases. These patients may be preventativelytreated to delay the onset of clinical symptomology. More specifically,patients who present initially with clinically isolated syndromes (CIS)may be treated using the treatment paradigm outlined in this invention.These patients have had at least one clinical event consistent with MS,but have not met full criteria for MS diagnosis since the definitediagnosis requires more than one clinical event at another time(McDonald et al., 2001). Treatment of the present invention would beadvantageous at least in preventing or delaying the development ofclinically definite MS.

PRIMARY AGENT. The primary agent useful in this invention is a hormone,more particularly an estrogen or a steroidal or non-steroidal estrogenreceptor active agent. The primary agent may be estriol(estra-1,3,5(10)-triene-3,16,17-triol, E3), such as estriol succinate,estriol dihexanate or estriol sulfmate. However, the primary agent maybe a precursor or analog of estriol (such as nyestriol), estrone (E1) orprecursors or analogs of estrone, 17α-estradiol, 17β-estradiol (E2) orprecursors (including aromatizable testosterone) or analogs of17β-estradiol.

The primary agent may also be a metabolite or derivatives of E1, E2 orE3 which are active at the estrogen receptor α or β. Metabolites andderivatives may have a similar core structure to E1, E2 or E3 but mayhave one or more different groups (ex. hydroxyl, ketone, halide, etc.)at one or more ring positions. Synthetic steroids which are effective atestrogen receptor are also useful in this invention, such as thosedescribed in WO 97/08188 or U.S. Pat. No. 6,043,236 to Brattsand,incorporated herein by reference.

The primary agent may also be an estrogen receptor α or β, agonistsand/or antagonist. These agonists or antagonists may be steroidal ornon-steroidal agents which bind to and/or cause a change in activity orbinding of at least one of the estrogen receptor α or β subtypes. Forexample, specific agonists of ER α and ER β may be useful in thisinvention (Fritzmeier, et al.). Doses of these agonists may be titratedto achieve an effect on disease similar to that which is observed duringpregnancy and during treatment with pregnancy doses of estriol bymethodologies known to those skilled in the art of steroid pharmacology.

Any one or combination of these estrogens or estrogen receptor activeagents may be used. The selection of the estrogens or estrogen receptoractive agents can be made considering secondary side effects of thetreatment to the patient. For example, estriol may be selected over17β-estradiol, because estriol causes minimal endometrial proliferationand is not associated with increased risk of breast cancer. Minimalendometrial proliferation is observed when the long-acting estriolderivative, nyestriol is used. Indeed, because estriol has partialantagonist action on the binding of 17β-estradiol to the estrogenreceptor in vivo, estriol was at one point in the past considered as atherapeutic agent for treatment and prevention of breast cancer.

THERAPEUTICALLY EFFECTIVE DOSAGE OF THE PRIMARY AGENT. A therapeuticallyeffective dose of the primary agent is one sufficient to raise the serumconcentration above basal levels, and preferably to pregnancy levels orabove pregnancy levels. Most preferably, the therapeutically effectivedosage of the primary agent is selected to result in serum levels in apatient equivalent to the steroid hormone level of that agent in womenin the second or third trimester of pregnancy.

For example, during the normal female menstrual cycle estradiol levelsare in the range of about 350 pg/ml serum. During pregnancy, there isabout a 100 fold increase in the level of estradiol to about 10,000 toabout 35,000 pg/ml serum. (Correale, et al., Journal of Immunology,161:3365 (1998) and Gilmore, et al., Journal of Immunology, 158:446.) Incontrast, estriol levels are undetectable during the menstrual cycle inthe non-pregnant state. Estradiol levels rise progressively duringpregnancy to levels from 3,000 to 30,000 pg/ml (3 to 30 ng/ml)(www.il-st-acad-sci.org/steroid1.html#se3t).

In one embodiment, where the primary agent is estriol, the preferabledose is from about 1 to 20 milligrams daily, and more specifically,about 5-10 milligrams daily, or about 8 milligrams daily. In thisembodiment, blood serum levels preferably reach at least about 2 ng/ml,may reach about 10 to about 35 ng/ml, or most preferably about 20-30ng/ml. (Sicotte et al., Neurology, 56:A75.) In some embodiments,estradiol (E2) levels would preferably reach at least about 2 ng/ml andmost preferably about to 10-35 ng/ml. In some embodiments, estrone (E1)levels would preferably reach at least about 2 ng/ml and most preferablyabout 5-18 ng/ml (DeGroot and Jameson, 1994).

In one embodiment, the dosage may be selected to be between about 0.1and 2.0 milligrams of α or β estradiol, or about 0.05 to 0.5 milligramsconjugated estrogen.

The dosage of the primary agent may be selected for an individualpatient depending upon the route of administration, severity of disease,age and weight of the patient, other medications the patient is takingand other factors normally considered by the attending physician, whendetermining the individual regimen and dosage level as the mostappropriate for a particular patient.

The use of this group of primary agents is advantageous in at least thatother known or experimental treatments for cellular mediated autoimmunediseases are chemotherapeutic immunosuppresants which have significantrisks and side effects to patients, including decreasing the ability ofthe patient to fight infections, inducing liver or heart toxicity whichare not caused by estrogen treatment. Other agents used in MS do notcause these side effects, but are associated with flu-like symptoms orchest tightness. Further, these previously used agents are associatedwith local skin reactions since they entail injections at frequenciesranging from daily to once per week.

DOSAGE FORM. The therapeutically effective dose of the primary agentincluded in the dosage form is selected at least by considering the typeof primary agent selected and the mode of administration. The dosageform may include the active primary agent in combination with otherinert ingredients, including adjutants and pharmaceutically acceptablecarriers for the facilitation of dosage to the patient as known to thoseskilled in the pharmaceutical arts. The dosage form may be any formsuitable to cause the primary agent to enter into the tissues of thepatient.

In one embodiment, the dosage form of the primary agent is an oralpreparation (liquid, tablet, capsule, caplet or the like) which whenconsumed results in elevated serum estrogen levels. The oral preparationmay comprise conventional carriers including dilutents, binders, timerelease agents, lubricants and disinigrants.

Possible oral administration forms are all the forms known from theprior art such as, tablets, dragees, pills or capsules, which areproduced using conventional adjuvants and carrier substances. In thecase of oral administration it has proved appropriate to place the dailyunits, which in case comprise a combination of the two agents, in aspatially separated and individually removable manner in a packagingunit, so that it is easy to check whether the typically daily taken,oral administration form has in fact been taken as it is important toensure that there are no taking-free days. Depot injections can beadministered at 1 to 6 months or longer intervals. Hormonal implantscontain both hormonal components and deliver the same over a period ofpreferably 3 to 6 months.

In other embodiments of the invention, the dosage form may be providedin a topical preparation (lotion, cream, ointment, patch or the like)for transdermal application. Alternatively, the dosage form may beprovided in a suppository or the like for intravaginal or transrectalapplication. Alternatively, the agents may be provided in a form forinjection or for implantation.

In the transdermal administration of the combination according to theinvention, the two hormonal agents may be applied to a plaster or alsocan be applied by transdermal, therapeutic systems and are consequentlysupplied to the organism. For example, an already prepared combinationof the two hormonal components or the latter individually can beintroduced into such a system, which is based on ionotherapy ordiffusion or optionally a combination of these effects.

That estrogens or estrogen receptor active agents can be delivered viathese dosage forms is advantageous in that currently availabletherapies, for MS for example, are all injectables which areinconvenient for the user and lead to decreased patient compliance withthe treatment. Non-injectable dosage forms are further advantageous overcurrent injectable treatments which often cause side effects in patientsincluding flu-like symptoms (particularly, β interferon) and injectionsite reactions which may lead to lipotrophy (particularly, glatirameracetate copolymer-1).

However, in additional embodiments, the dosage form may also allow forpreparations to be applied subcutaneously, intravenously,intramuscularly or via the respiratory system.

SECONDARY ACTIVE AGENTS. Any one or a combination of secondary activeagents may be included in the dosage form with the primary agent.Alternatively, any one or a combination of secondary active agents maybe administered independently of the primary agent, but concurrent intime such that the patient is exposed to at least two agents for thetreatment of their immunological disease.

The secondary agents are preferably immunotherapeutic agents, which actsynergistically with the primary agent to diminish the symptomology ofthe autoimmune disease. Secondary active agents may be selected toenhance the effect of the estrogen or estrogen receptor active agent,reduce the effect of the estrogen or estrogen receptor active agent oreffect a different system than that effected by the estrogen or estrogenreceptor active agent.

Secondary active agents include immunotherapeutic agents which cause achange in the activity or function of the immune system.

In one embodiment, a secondary agent may be a therapeutically effectiveamount of one or more gestagens, for example, progesterone,chlormadinone acetate norethisterone acetate, norethindrone, cyproteroneacetate, desogestrel, levonorgestrel, other natural and/or syntheticgestagens, antigestagens and hormonal compounds which split off at leastone gestagen following taking. For example, the gestagen may be aprogesterone, precursor, analog or progesterone receptor agonist orantagonist. In one embodiment, the secondary agent is 100-200 milligramsof progesterone administered daily. Progesterone in combination withestrogen or estrogen receptor active agent treatment is advantageous inat least protecting patients against risks associated with long termestrogen exposure, including, but not limited to endometrialproliferation and breast cancers.

Norethindrone may be selected as the secondary agent in premenopausaland perimenopausal women cycling (age 18-50 approximately) at doses of0.35 mg per day continuously. If breakthrough bleeding occurs, then thedose may be increased to 0.70 mg per day temporarily (for 2-6 months).Then the lower dose of 0.35 mg per day may be resumed.

Norethindrone can also be given in noncycling, menopausal women (ageover 50 approximately) at minimal doses of 0.70 mg per day for about 2-4weeks duration, every 2-4 month, and more specifically every about 3months. In this manner, when norethindrone is given for 2 weeks every 3months.

By way of further example, the compositions may be formulated andtreatment provided, such that the composition comprises about 1-20 mgestriol and about 0.2-3 mg norethindrone. Further, the composition mayinclude norethindrone administered at doses of about 0.5 to 3.0 mg perday for a period of about 2-4 weeks, then the dose of norethindrone mayreduced to a dose of about 0.2 to 0.5 mg thereafter.By way of further example, the compositions may be formulated andtreatment provided, such that the composition comprises about comprisingabout 1-20 mg estriol and about 50-100 mg progesterone. Further,progesterone may be administered at doses of about 50-100 mg per day fora period of about 2-4 weeks, then the dose of progesterone may bereduced to a dose of about 25-50 mg thereafter. A higher dose may givenat a selected interval (such as every 2-4 weeks) for a selected periodof time (such as every 2-4 months) to diminish endometrialproliferation.

The secondary agent is advantageous at least in preventing endometrialproliferation which may arise from prolonged use of estrogens, such asestriol.

In another embodiment, a third agent may be added to the combination ata therapeutically effective amount. Preferably the third agent may beadministered at a lower dose due to the synergistic effect with thecombination of the first and second agents. Examples include aglucocorticoid, precursor, analog or glucocorticoid receptor agonist orantagonist. For example, prednisone may be administered, most preferablyin the dosage range of about 5-60 milligrams per day. Also, methylprednisone (Solumedrol) may be administered, most preferably in thedosage range of about 1-2 milligrams per day. Glucocorticoids arecurrently used to treat relapse episodes in MS patients, and symptomaticRA within this dosage range.

In other embodiments, a third agent may be selected from the groupimmunotherapeutic compounds. For example, as β-interferon (Avonex®(interferon-beta 1a), Rebiff® (by Serono); Biogen, Betaseron®(interferon-beta 1b; Berlex, Schering), glatiramer acetate copolymer-1(Copaxone®; Teva), antineoplastics (such as mitoxantrone; Novatrone®Lederle Labs), human monoclonal antibodies (such as natalizumab;Antegren® Elan Corp. and Biogen Inc.), immonusuppressants (such asmycophenolate mofetil; CellCept® Hoffman-LaRoche Inc.), paclitaxel(Taxol®; Bristol-Meyers Oncology), cyclosporine (such as cyclosporin A),corticosteroids (glucocorticoids, such as prednisone and methylprednisone), azathioprine, cyclophosphamide, methotrexate, cladribine,4-aminopyridine and tizanidine.

By way of example, which is consistent with the current therapeutic usesfor these treatments, Avonex® in a dosage of about 0 to about 30 mcg maybe injected intramuscularly once a week. Betaseron® in a dosage of about0 to about 0.25 mg may be injected subcutaneously every other day.Copaxone® in a dosage of about 0 to about 20 mg may be injectedsubcutaneously every day. Finally, Rebiff® may be injected at atherapeutic dose and at an interval to be determined based on clinicaltrial data. However, dosages and method of administration may be alteredto maximize the effect of these therapies in conjunction with estrogentreatment. Dosages may be altered using criteria that are known to thoseskilled in the art of diagnosing and treating autoimmune diseases.

Preferably, a third secondary agent would be administered in the dosageranges currently used to treat patients having autoimmune diseases,including MS patients. Alternatively, the third agent may beadministered at a reduced dose or with reduced frequency due tosynergistic or duplicative physiological effects with the primary andsecondary agents.

Preferably, patients exhibiting symptomology of autoimmune diseases aretreated with the above agents. Most preferably, patients exhibitautoimmune diseases marked by improvement in delayed onset orsymptomology at least during a treatment regimen, including but notlimited to that reflecting patterns observed during the second or thirdtrimester of pregnancy.

In one embodiment the invention may achieve a continuous, combinedadministration of a product comprising two hormonal components, namely afirst pregnancy hormonal component comprising, an estrogen or pregnancyhormone, such as estriol, and a second hormonal component comprising atleast one gestagen, so that a continuous uninterrupted steady state ofhormones can be administered to female patients (premenopausal orpostmenopausal) suffering from autoimmune diseases (such as multiplesclerosis) and thereby reduce the onset and severity (such as relapserates) of such disease. The invention also contemplates various dosingregiments whereby one or more gestagens are administered at higher dosesfor shorter periods of time to reduce endometrial side effectsassociated with hormonal treatment.

Currently, estrogens are not understood to cover steroid molecules,which preferably evolve their action in that they in different waysexert a biological effect at different cell locations in differentorgans. Estrogens can act on at least: (1) the cellular membrane, (2)intracellular, cytoplasmic proteins and (3) specific nuclear receptors.It has recently become known that besides the standard estrogen receptortype 1 there is a second estrogen receptor type 2, whose organdistribution is different from that of the estrogen receptor type 1.Thus, estrogens also include the compounds known as designer hormones,which have the aforementioned characteristics.

Biogenous estrogens include those estrogens which are produced by thehuman body and consequently include endogenic estrogens. The biogenousestrogens used in specific embodiments of the invention may beendogenous those which are chemically synthesized. However, it isfundamentally also possible to use compounds isolated from an organism.

Thus, biogenous estrogens include steroid molecules, which evolve anestrogen-like action on the membrane, cytoplasmic proteins and nuclearreceptors for hydrophobic ring substances and consequently triggerbiological effects corresponding to a hydrophobic steroid ring structureable to initiate an estrogen-like action in cells, organs and thecomplete organism.

Biogenous estrogens also include conjugate, biogenous estrogens, such asestradiol valerate and estrone sulphate.

Antiestrogens include hydrophobic ring structure substances and othersubstances able to specifically and selectively counteract theabove-described estrogen action on cells, organs or the overallorganism.

Continuous administration of agents in accordance with this disclosureincludes an administration uninterrupted over the use period, in whichthere are no hormonal component taking-free intervals. This means thatthere is no planned interruption of the administration of the agents byadministering placebos in place of the agents. Thus, over the entireadministration period, the hormonal components forming the combinationor agents according to the invention are administered uninterrupted. Insome embodiments, the dosages of agents also remains unchanged. However,in some embodiments, the dosage of estrogen (understood in the fullbreadth of the concept defined here), and gestagen (also understood inthe full breadth of the term defined here), can be difference for olderwomen compared with younger women. This can also take place in such away that over the continuous administration period initially there is astart with a specific dosage and this is then adapted over a period ofweeks, months and/or years to the changed biological needs of the womenthrough the administration of a subsequent dosage, but which alsocomprises a combination of primary and secondary agents according to thepresent invention.

As a result of the continuous administration of the primary andsecondary agents, the natural hormonal processes taking place in thefemale organism do not interrupt contraceptive security.

It has surprisingly also been found that on administering thecombination according to the invention there is a reliable continuoussuppression of the menstrual cycle and menstruation in the case of avery low dosage. Without wishing to be bound by this explanation, thecombination of the hormonal components, and in particular the lowestrogen dosage would appear to be suitable for eliminating theotherwise conventional side effects of estriol and to drop below theadministrations of more than 15 mg of estriol otherwise consideredtypically necessary in prior art contraceptives.

As a result of the estrogen component, respectively by specific actionof hydrophobic ring substances with an estrogen-like action, there canbe a suppression of gonadotropins. This is desirable. The resultingsuppression of the ovarian function is compensated by an adequatesubstitution of estrogen action. This prevents the development ofosteoporosis, the favorable vascular effects of estrogens aremaintained, and there is no unfavorable influence to the lipidmetabolism. By interrupting the cycle-dependent instability in thehormone system, premenstrual syndrome can be favorably influenced. Inaddition, the physiological equilibrium of the coagulation system is notdisturbed, because the unstable equilibrium in which the coagulationsystem occurs is not activated and deactivated by the up and down ofhormone fluctuations. Thus, the combination according to the inventionis particularly suitable for women aged more than 40, where the risk ofcirculatory disturbances is known to increase with increasing age. Thereis also a reduction in the thrombosis risk, which has of late acquiredconsiderable significance in contraceptive therapy.

The low dosages of the two hormonal components, and in particular theestrogen component, is made possible by the additive action of the twohormonal components, without there being any limitation to the action ofthe combination according to the invention with respect to itscontraceptive and ovulation-inhibition properties.

KITS. In another aspect of this invention kits are provided for use bythe treating physician in the clinic or prescribed patient forself-administration of treatment. The kits of this invention include atleast one primary agent and one secondary agent in the appropriatedosages and dosage form for the treatment of the patient's clinicalsymptoms.

In one embodiment of the kit, the primary agent is estriol in doses ofabout 1-20, or about 5-10, or about 8 milligrams and the secondary agentis a gestagen, such as progesterone in doses of about 100 to about 200milligrams. In a second embodiment of this kit, the primary agent isestradiol in doses of about 0.1 to 2 milligrams and the secondary agentis a gestagen.

In a third embodiment of this invention, the kit may also include athird agent of β-interferon in doses of about 0.25 milligrams ofBetaseron® or about 30 mcg of Avonex®. In a fourth alternate embodimentof the kit, the third agent may be glatiramer acetate copolymer in dosesof about 20 milligrams of Copaxone®.

The kit also preferably contains instructions for use of the kit by theuse by the treating physician or patients to treat their autoimmunedisease. Such information would include at least the schedule for theadministration of the primary and secondary agent doses and, ifincluded, a third agent dose.

Although the present invention has been described in terms of thepreferred embodiment above, numerous modifications and/or additions tothe above-described preferred embodiments would be readily apparent toone skilled in the art.

EXAMPLE 1

Methods: Trial Design. A crossover design was used with monthly brainMRIs during the six month pretreatment period, the six month treatmentperiod with oral estriol (8 milligrams/day) and the six month posttreatment period, with clinical and laboratory evaluations asdemonstrated (FIG. 1A).

Inclusion Criteria. Women with clinically definite MS, ages 18-50, withan EDSS 0-6.5 who had been off interferon beta and copolymer-1 for atleast six months, and had no steroid treatment for at least three monthswere eligible. At least 5 cm³ of lesion burden on a screening T2weighted brain MRI was required. Subjects who were pregnant or nursing,on oral contraceptives or hormone replacement therapy, or who had ahistory of thrombosis, neoplasm or gynecologic disease, or who had beentreated in the past with total lymphoid irradiation, monoclonalantibody, T cell vaccination, cladribine or bone marrow transplantationwere excluded.

Patients. Twelve female patients with clinically definite MS wereenrolled. Six had RR disease and six had SP disease. All six RR and fourof six SP patients completed the entire 18 month study period. One SPpatient was discontinued from the study because of prolonged treatmentwith steroids for tonic spasms by an outside neurologist and the otherdid not wish to go untreated in the post treatment period. Of the tenpatients who completed the entire study, the mean age was 44 years(range 28 to 50 years) and the mean EDSS was 3.3 (range 1.0 to 6.5). Themean EDSS score for the SP patients was 5.0 while the mean EDSS for theRR patients was 2.2. The 18 month trial was extended in RR patientswhereby treatment was re-instituted.

Medication. For the initial treatment phase, micronized, U.S.P. gradedestriol powder (Medisca, Inc., Plattsburg, N.Y.) was put into capsulesby UCLA Pharmaceutical Services. During the extension re-treatment phasein the RR patients, all but one received a capsule of estriol (8milligrams/day) plus progesterone (100 milligrams/day), while the singleRR patient who had a hysterectomy received only estriol (8milligrams/day) (Women's International Pharmacy, Madison, Wis.).

Clinical and Safety Measures. Subjects were evaluated using theKurtzke's Expanded Disability Status Scale (EDSS) by the sameneurologist (RV) throughout the study. At each visit the study nurse(RK) administered the paced auditory serial addition test (PASAT) andthe 9-hole peg test. Blood was drawn for SMA12, cholesterol panel, bloodcounts and hormone levels (estriol, estradiol, estrone, LH, FSH,cortisol, progesterone). Estriol levels in serum were determined byELISA according to manufacturer's instructions (Oxford Biomedical,Oxford, Mich.).

Delayed Type Hypersensitivity Responses (DTH). DTH to tetanus (TetanusToxoid, Wyeth Laboratories, Marietta, Pa.) and candida (Candin, AllermedLaboratories, San Diego, Calif.) were tested at two timepoints, once inthe pretreatment period at study month 3 and once at the end of thetreatment period at study month 12 (FIG. 1 a). A group of six untreatedhealthy control women were also tested twice, spanning the same timeinterval (9 months). 0.1 ml of each solution was injected intradermallyon the anterior surface of the forearm. Induration at each injectionsite was read after 48 hours. Each site was measured twice, oncevertically and once horizontally with the average recorded. The samenurse (RK) administered all injections and read all responses on allsubjects at both time points.

Reverse Transcription and Polymerase Chain Reaction. Peripheral bloodmononuclear cells (PBMCs) were isolated from heparinized venous bloodand cryopreserved. PBMCs were thawed in parallel from a given patientduring the two pre-treatment timepoints and the two treatmenttimepoints. Total RNA was isolated, DNA was removed and mRNA was reversetranscribed. Both IFN-γ and actin were amplified from the same cDNA,however, the cDNA was diluted 1:9 prior to amplification for actin.Amplification was done in 1 mM Milligrams Cl₂ using IFN-γ and actinprimer sequences (Life Technologies, Rockville, Md.). Complementary DNAwas amplified for 35 cycles: 45″ @95° C., 60″ @54° C. and 45″ @72° C.PCR products were separated on a 1.5% agarose gel containing ethidiumbromide and densitometry performed.

MRIs. Scans were performed on a 1.5T General Electric scanner. The pulsesequences obtained were a T1-weighted scan with and without gadolinium(Omniscan 0.1 mmol/kg) and a PD/T2 weighted scan. Digitized image datawas transferred to a SGI workstation (Silicon Graphics, Inc) for furtherprocessing. The number and volume of new and total gadolinium enhancinglesions was determined using a semiautomated threshold based technique(Display, Montreal Neurological Institute) by a single experiencedoperator (NS). The operator was blinded as to whether patients had RR orSP disease. To calculate T2 volumes, a custom semiautomated, thresholdbased, seed-growing algorithm was used to determine lesion volume afterskull stripping, rf correction and spatial normalization. All scans werecounted by the same technician who was blinded as to whether patientshad RR or SP disease.

Statistical Analysis. One sample, paired, t-tests were used to ascertainsignificance of percent changes in DTH responses, IFN-γ levels and PASATcognitive testing scores during treatment as compared to pretreatment.The nonparametric, Wilcoxon's signed rank test was used for statisticalcomparisons in enhancing lesion numbers and volumes on MRI between thesix month baseline period and each treatment period, post treatmentperiod and re-treatment period.

Results. Estriol levels and tolerability. Serum estriol levels duringtreatment and re-treatment approximated those observed in women who weresix months pregnant, but were lower than those who were 8.5 monthspregnant (FIG. 1 b). Consistent with previous reports, estriol was welltolerated with only menstrual cycle abnormalities. There were nosignificant alterations in any laboratory measures including LH, FSH,cortisol, progesterone, estradiol and estrone.

Immune Responses. Skin testing to tetanus and-candida were performedonce in the pretreatment period and once at the end of the treatmentperiod to determine whether they might be decreased with treatment. DTHresponses to tetanus were significantly, P=0.006, decreased at studymonth 12, when patients had been on estriol for six months, as comparedto DTH responses at study month 3, the pretreatment baseline (FIG. 2 a).DTH responses to candida were decreased less dramatically and morevariably. The significant decrease in DTH responses to tetanus frompretreatment (month 3) to treatment (month 12) was not merely due torepeat testing at nine months since healthy, untreated female controlstested at baseline, then again after nine months, did not demonstrate asignificant decrease in DTH responses as compared to their baseline.These findings are consistent with an estriol induced down-regulation ofTh1 responses in vivo during treatment.

IFN-γ is a signature cytokine for Th1 responses. Therefore, we assessedIFN-γ levels by RT-PCR of unstimulated peripheral blood mononuclearcells (PBMCs) derived ex vivo from patients during the pretreatment andthe treatment periods. In the six RR patients, levels of IFN-γ werevariably decreased at study month 9 (after three months of estrioltreatment) and then significantly decreased, P=0.003, at study month 12(after six months of estriol treatment) as compared to baselinepretreatment levels (months 3 and 6) (FIG. 2 b). In contrast, there wasno decrease in IFN-γ in the four SP patients. These data are consistentwith the concept that the immune system of RR patients, as compared toSP patients, may be more amenable to treatments that aim to decrease Th1responses. Also, the observation that estriol treatment can altercytokine production by PMBCs is consistent with reports demonstratingestrogen receptors α and β in immune tissues and cells.

MRIs. Based on the protective effect of pregnancy on relapse rates in MSpatients and the association of gadolinium enhancing lesions withrelapses, we hypothesized that estriol treatment would have ananti-inflammatory effect as manifested by decreases in enhancing lesionson serial brain MRIs. Compared to the six month pretreatment baselineperiod, the total volume and number of enhancing lesions for all ten MSpatients (6RR, 4SP) decreased during the treatment period. Thisimprovement in the group as a whole was driven by the beneficial effectof estriol treatment in the RR, not the SP, group (FIGS. 3 a and 3 b).Therapeutic effects of estriol treatment in the RR group were thereforeexamined in further detail. Within the first three months of treatmentof RR patients, median total enhancing lesion volumes were decreased by79%, P=0.02, and numbers were decreased by 82%, P=0.09 (FIGS. 3 c and 3d). They remained decreased during the next three months of treatment,with lesion volumes decreased by 82%, P=0.01, and numbers decreased by82%, P=0.02. In the post treatment period, median total enhancing lesionvolumes and numbers became variable in the first three months offtreatment, before returning to near baseline levels in the last threemonths of the post treatment period. During the four month re-treatmentextension phase, enhancing lesion volumes decreased again by 88%,P=0.008, and numbers decreased again, this time by 48%, P=0.04, ascompared to original baseline (FIGS. 3 c and 3 d). Changes in median newenhancing lesion volumes and numbers followed similar patterns as mediantotal lesion numbers and volumes (FIGS. 3 e and 3 f).

Median T2 lesion volumes for the whole group were 15.3 cm³ (range6.1-33.8), with no significant differences in median T2 volumes betweenRR and SP groups. Consistent with enhancing lesion data, serial T2lesion volumes revealed that estriol treatment tended to be mostbeneficial in RR patients. In the RR group, median T2 lesion volumesremained stable during the six month treatment period (0% change),increased during the six month post treatment period (7.4% higher), andthen declined in the four month re-treatment extension period (2.0%lower).

Clinical Measures. Relapses were few and showed no significant changesduring the study. In the six RR patients, one relapse occurred duringthe pretreatment period, one in the treatment period, two in the posttreatment period and none in the re-treatment period. No relapsesoccurred in SP patients. EDSS and 9 Hole Peg Test scores showed nosignificant changes during the study (Table 1).

TABLE 1 Clinical Measures Pretreatment Estriol Treatment Post Treatment3 mo. 6 mo. 9 mo. 12 mo. 15 mo. 18 mo. EDSS scores 6 RR 2.2 2.0 1.5 1.71.8 1.8 (0.6) (0.5) (0.7) (0.6) (0.6) (0.5) 4 SP 5.0 5.0 4.9 5.0 5.1 5.0(0.9) (0.9) (1.0) (0.9) (1.1) (0.8) 9 Hole Peg Test scores 6 RR R 22.221.8 22.5 21.5 21.0 21.4 (2.4) (1.6) (2.3) (1.9) (1.7) (2.4) L 24.8 22.924.3 23.3 23.0 22.7 (3.2) (1.6) (2.5) (2.1) (2.1) (2.3) 4 SP R 26.8 29.930.2 33.7 29.4 34.0 (0.8) (2.4) (1.4) (4.8) (5.2) (8.7) L 23.5 25.6 22.724.8 26.7 25.0 (1.4) (2.5) (1.7) (2.6) (0.7) (1.8)

Interestingly, PASAT cognitive testing scores were significantlyimproved in the RR-group, but not in the SP group (FIG. 4). Thisimprovement in PASAT scores in RR patients by 14.0% during treatment ascompared to baseline, reached statistical significance, P=0.04. It isunlikely that this improvement was entirely due to a practice effect ofrepeated testing because of the long time interval between testing (9months) and because alternate versions of the test were used in eachpatient. This beneficial effect of estriol treatment on PASAT scores ofRR MS patients is consistent with previous reports describing abeneficial effect of estrogen replacement therapy in surgicallymenopausal women and high dose estrogen treatment in Alzheimer'sdisease. (Sicottte, et al., Treatment of Women with Multiple SclerosisUsing Pregnancy Hormone Estradiol: A Pilot Study. Neurology, 56 (8 Supp.3):A75, April 2001, and Sicottte, et al., Treatment of MultipleSclerosis with the Pregnancy Hormone Estradiol, Submitted to Neurology2002), herein incorporated by reference.

EXAMPLE 2

Progesterone in combination with estrogen treatments has been shown toprotect against endometrial proliferation and cancer. Indeed, estrogencannot be given for a lengthy period of time in an “unopposed” fashionin any woman with a uterus. Thus, seven of the 12 patients wanted toremain on estriol after completion of the 18 month study. These patientswere then put back on 8 milligrams of estriol and 100 milligrams ofprogesterone per day. In an extension phase of the study which beganafter completion of the post treatment phase. This extension phase was 4months in duration. Each of the seven patients had an MRI every monthduring the 4 month extension phase. Additionally, each of the sevenpatients was examined neurologically and had serologic studies done atthe end of this phase. No known negative effects 100 milligrams ofprogesterone in combination therapy with 8 milligrams of estrioltreatment were noted.

EXAMPLE 3

Method. A 33 year old white female relapsing remitting MS patient wastreated with estriol 8 mg/day and norethindrone 0.35 mg/day, incombination with Copazone injections, to try to prevent post partumrelapses which are known to occur at months 3-6 post partum.

History. Previously, when the patient had her first child (now age 7),she was treated with Copaxone (standard of MS care) and norethindrone(the progesterone only birth control pill) and relapsed at 6 weeks. Whenthe patient had her second child (now age 3), she was again treated withCopaxone and norethindrone and again relapsed, this time at 4.5 months.

Results. When the patient had her third child (now 6 months of age), sheresumed treatment with Copaxone as before. However on day 10 post partumshe began taking estriol 8 mg orally each day in combination withnorethindrone 0.35 mg/day. She had no relapses in the entire 6 monthpost partum period, and her neurologic exam remained unchanged withminimal disability (EDSS=1). Since monthly brain MRIs with gadolinium todetect enhancing MS lesions are more sensitive for inflammatory diseaseactivity than clinical relapses, the patient underwent serial monthlyMRIs at post partum months 4, 5, and 6. There was no enhancement atmonth 4, only one small enhancing lesion at month 5, and at 6 monthsonly a small residual, less robust enhancement of the single lesion fromthe previous month. No new enhancement was observed at month 6. The T2lesion load remained stable throughout.

She has had increased irregular menstrual bleeding despite using theprogesterone minipill, one pill per day since day 10, to stabilize theuterine endometrium and for birth control. Uterine ultrasounds at month3 and 6 showed a thin, not thick, endometrium, consistent with anunstable lining, not suggestive of hyperplasia. The patient doubled theprogesterone minipill for 2 weeks (0.70 mg/day) to stabilize theendometrium. Otherwise no adverse events have been reported.

In closing, it is noted that specific illustrative embodiments of theinvention have been disclosed hereinabove. However, it is to beunderstood that the invention is not limited to these specificembodiments.

Accordingly, the invention is not limited to the precise embodimentsdescribed in detail hereinabove. With respect to the claims, it isapplicant's intention that the claims not be interpreted in accordancewith the sixth paragraph of 35 U.S.C. §112 unless the term “means” isused followed by a functional statement.

While the specification describes particular embodiments of the presentinvention, those of ordinary skill can devise variations of the presentinvention without departing from the inventive concept.

What is claimed is:
 1. A method for treating at least one sign orsymptom of multiple sclerosis, comprising administering to a subject,for a continuous administration period, a gestagen and estriol.
 2. Themethod of claim 1, wherein the estriol is administered at a dosage ofabout 1-20 milligrams per day.
 3. The method of claim 1, wherein theestriol is administered at a dosage of about 5-10 milligrams per day. 4.The method of claim 1, wherein the estriol is administered at a dosageof about 8 milligrams per day.
 5. The method of claim 1, wherein thegestagen is selected from the group comprising progesterone,chlormadinone acetate, northisterone acetate, norethindrone, andcyprotherone acetate.
 6. The method of claim 1, in which the patient isa premenopausal, perimenopausal or postmenopausal female.
 7. A method ofclaim 1, further comprising administering a third agent selected fromthe group comprising: glatiramer acetate, interferon-β 1a, interferon-β1b and sphingosine-1-phosphate receptor modulator.
 8. The method ofclaim 1, wherein the administration is oral.
 9. The method of claim 1,wherein the administration period is 12 months.
 10. A method forpreventing at least one sign or symptom of multiple sclerosis,comprising administering to a subject, for a continuous administrationperiod, a gestagen and estriol.
 11. The method of claim 10, wherein theestriol is administered at a dosage of about 1-20 milligrams per day.12. The method of claim 10, wherein the estriol is administered at adosage of about 5-10 milligrams per day.
 13. The method of claim 10,wherein the estriol is administered at a dosage of about 8 milligramsper day.
 14. The method of claim 10, wherein the gestagen is selectedfrom the group comprising progesterone, chlormadinone acetate,northisterone acetate, norethindrone, and cyprotherone acetate.
 15. Themethod of claim 10, in which the patient is a premenopausal,perimenopausal or postmenopausal female.
 16. A method of claim 10,further comprising administering a third agent selected from the groupcomprising glatiramer acetate, interferon-β 1a, interferon-β 1b andsphingosine-1-phosphate receptor modulator.
 17. The method of claim 10,wherein the administration is oral.
 18. The method of claim 10, whereinthe administration period is 12 months.
 19. A method for treating atleast one sign or symptom of multiple sclerosis, comprisingadministering to a subject for a continuous administration period aneffective amount of a gestagen and estriol.
 20. The method of claim 19,wherein the estriol is administered at a dosage of about 1-20 milligramsper day.
 21. The method of claim 19, wherein the estriol is administeredat a dosage of about 5-10 milligrams per day.
 22. The method of claim19, wherein the estriol is administered at a dosage of about 8milligrams per day.
 23. The method of claim 19, wherein the gestagen isselected from the group comprising progesterone, chlormadinone acetate,northisterone acetate, norethindrone, and cyprotherone acetate.
 24. Themethod of claim 19, in which the patient is a premenopausal,perimenopausal or postmenopausal female.
 25. A method of claim 19,further comprising administering a third agent selected from the groupcomprising glatiramer acetate, interferon-β 1a, interferon-β 1b andsphingosine-1-phosphate receptor modulator.
 26. The method of claim 19,wherein the administration is oral.
 27. The method of claim 19, whereinthe administration period is 12 months.
 28. A method of delaying theonset of at least one sign or symptom of multiple sclerosis, comprisingadministering estriol for a period of approximately 6 months, andthereafter administering a combination of estriol and a gestagen.
 29. Amethod of delaying the onset of at least one sign or symptom of multiplesclerosis comprising administering estriol and interferon-β 1a for aperiod of about 6 months, and thereafter administering a combination ofestriol, interferon-β 1a and a gestagen.
 30. A method of delaying theonset of at least one sign or symptom of multiple sclerosis comprisingadministering estriol and interferon-β 1b for a period of about 6months, and thereafter administering a combination of estriol,interferon-β 1b and a gestagen.
 31. A method of treating at least onesign or symptom of multiple sclerosis, comprising administering estriolfor a period of approximately 6 months, and thereafter administering acombination of estriol and a gestagen.
 32. A method of treating at leastone sign or symptom of multiple sclerosis comprising administeringestriol and interferon-β 1a for a period of about 6 months, andthereafter administering a combination of estriol, interferon-β 1a and agestagen.
 33. A method of treating at least one sign or symptom ofmultiple sclerosis comprising administering estriol and interferon-β 1bfor a period of about 6 months, and thereafter administering acombination of estriol, interferon-β 1b and a gestagen.